Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video

Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital... Abstract We present a 43-old-male who suffered from a slowly progressive loss of vision in the left eye. Magnetic resonance (MR) imaging revealed a well-circumscribed contrast-enhancing lesion in the region of the anterior cavernous sinus and superior orbital fissure that extended into the optic canal. A schwannoma or meningioma was suspected. A transcranial surgery performed at another institution was not successful in removing the tumor and further deterioration of vision occurred. After resection of the left middle turbinate, the sphenoid and maxillary sinus were opened. The bulging of the tumor was seen at the lateral wall of the sphenoid sinus. After bony decompression of the optic canal, the dura was opened. A meningioma was exposed that arose in between the dural layers of the cavernous sinus. A nice dissection plane was found and the tumor was circumferentially dissected and finally totally removed. There were no complications such as double vision or visual field deficit. MR imaging confirmed a total tumor resection. The visual acuity normalized within a few days. MR imaging obtained 3 yr after surgery shows no recurrence. Transmaxillary, Endonasal, Cavernous sinus, Meningiomas Disclosures Dr Schroeder is a consultant for Karl Storz, GmbH, Tutlingen, Germany. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy093 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy093 Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video Close COMMENTS This is a very instructive and well narrated video demonstrating transnasal endoscopic assisted removal of a superior orbital fissure-intracavernous meningioma. The surgery is very expertly performed and shows the tremendous advantage of this approach over the more traditional intracranial approach. This video also shows the power of modern endoscopic techniques when used in the transnasal approach to tumors in the sellar and parasellar areas. William F. Chandler Ann Arbor, Michigan Endoscopic endonasal approaches to the skull base have evolved over the last few decades with increasing technological advancements and surgeon familiarity with these approaches. Transsphenoidal resection of pituitary lesions was the natural starting point, in that the sella is in the midline and easily accessible with a standard EEA. Taking advantage of the superior visualization afforded by endoscopes, neurosurgeons and rhinologists have gradually extended these boundaries and are now able to access through the nose lesions from the cribiform to C2 and laterally to Meckel's cave, middle fossa, and even the posterior fossa with extended approaches.1 Here the authors provide a nice video summary of an extended transmaxillary approach to an anterolateral cavernous sinus meningioma. As with most endonasal approaches, surgery starts in the midline with opening of the sphenoid sinus. Lateral exposure is gained through the maxillary sinus and pterygopalatine fossa; as mentioned, a 30° endoscope may be used to improve visualization laterally. More posterior extension is carefully undertaken only after clearly identifying the internal carotid artery. The authors highlight key anatomic relations among the optic nerve, carotid artery, lateral opticocarotid recess, knowledge of which allows safe removal of the bony optic strut and decompression of the optic canal. Tumor resection is then carried out by careful bimanual dissection technique, which is important for avoiding injury to the nerves in the lateral cavernous sinus. Increasing our proficiency with these extended endoscopic endonasal approaches will allow us to offer our patients potentially less invasive options for tackling difficult to access lesions of the skull base. Kevin K.H. Chow Griffith R. Harsh IV Stanford, California 1. De Lara D, Ditzel Filho LF, Prevedello DM, et al. Endonasal endoscopic approaches to the paramedian skull base. World Neurosurgery . 2014; 82( 6 Suppl): S121- S129. Google Scholar CrossRef Search ADS PubMed  Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Operative Neurosurgery Oxford University Press

Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video

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Publisher
Congress of Neurological Surgeons
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
2332-4252
eISSN
2332-4260
D.O.I.
10.1093/ons/opy093
Publisher site
See Article on Publisher Site

Abstract

Abstract We present a 43-old-male who suffered from a slowly progressive loss of vision in the left eye. Magnetic resonance (MR) imaging revealed a well-circumscribed contrast-enhancing lesion in the region of the anterior cavernous sinus and superior orbital fissure that extended into the optic canal. A schwannoma or meningioma was suspected. A transcranial surgery performed at another institution was not successful in removing the tumor and further deterioration of vision occurred. After resection of the left middle turbinate, the sphenoid and maxillary sinus were opened. The bulging of the tumor was seen at the lateral wall of the sphenoid sinus. After bony decompression of the optic canal, the dura was opened. A meningioma was exposed that arose in between the dural layers of the cavernous sinus. A nice dissection plane was found and the tumor was circumferentially dissected and finally totally removed. There were no complications such as double vision or visual field deficit. MR imaging confirmed a total tumor resection. The visual acuity normalized within a few days. MR imaging obtained 3 yr after surgery shows no recurrence. Transmaxillary, Endonasal, Cavernous sinus, Meningiomas Disclosures Dr Schroeder is a consultant for Karl Storz, GmbH, Tutlingen, Germany. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy093 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy093 Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video Endoscopic Endonasal Transmaxillary Transshpenoidal Approach for Excision of a Superior Orbital Fissure-Cavernous Sinus Meningioma: 2-Dimensional Operative Video Close COMMENTS This is a very instructive and well narrated video demonstrating transnasal endoscopic assisted removal of a superior orbital fissure-intracavernous meningioma. The surgery is very expertly performed and shows the tremendous advantage of this approach over the more traditional intracranial approach. This video also shows the power of modern endoscopic techniques when used in the transnasal approach to tumors in the sellar and parasellar areas. William F. Chandler Ann Arbor, Michigan Endoscopic endonasal approaches to the skull base have evolved over the last few decades with increasing technological advancements and surgeon familiarity with these approaches. Transsphenoidal resection of pituitary lesions was the natural starting point, in that the sella is in the midline and easily accessible with a standard EEA. Taking advantage of the superior visualization afforded by endoscopes, neurosurgeons and rhinologists have gradually extended these boundaries and are now able to access through the nose lesions from the cribiform to C2 and laterally to Meckel's cave, middle fossa, and even the posterior fossa with extended approaches.1 Here the authors provide a nice video summary of an extended transmaxillary approach to an anterolateral cavernous sinus meningioma. As with most endonasal approaches, surgery starts in the midline with opening of the sphenoid sinus. Lateral exposure is gained through the maxillary sinus and pterygopalatine fossa; as mentioned, a 30° endoscope may be used to improve visualization laterally. More posterior extension is carefully undertaken only after clearly identifying the internal carotid artery. The authors highlight key anatomic relations among the optic nerve, carotid artery, lateral opticocarotid recess, knowledge of which allows safe removal of the bony optic strut and decompression of the optic canal. Tumor resection is then carried out by careful bimanual dissection technique, which is important for avoiding injury to the nerves in the lateral cavernous sinus. Increasing our proficiency with these extended endoscopic endonasal approaches will allow us to offer our patients potentially less invasive options for tackling difficult to access lesions of the skull base. Kevin K.H. Chow Griffith R. Harsh IV Stanford, California 1. De Lara D, Ditzel Filho LF, Prevedello DM, et al. Endonasal endoscopic approaches to the paramedian skull base. World Neurosurgery . 2014; 82( 6 Suppl): S121- S129. Google Scholar CrossRef Search ADS PubMed  Copyright © 2018 by the Congress of Neurological Surgeons

Journal

Operative NeurosurgeryOxford University Press

Published: Apr 28, 2018

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